Patient Form 1.23.11.2 – Karta Pacjenta / Patient Form

PERSONAL AND CONTACT DATA

I. PATIENT DATA

First and Last name

Country

Address of residence

*PESEL (Polish personal ID no.)*

*Date of birth

*E-mail address

*Phone no.

II. **LEGAL REPRESENTATIVE DATA

*Does the patient have a legal representative?

Yes

No

*First name and last name

Address of residence

*PESEL (Polish personal ID no.)

*Date of birth

e-mail address

*phone no.

INSTRUCTION FOR THE PATIENT

*in the case of persons who do not have a PESEL (Polish personal ID no.), please indicate the series and number of the passport

**fill in only when the Patient is represented by a legal representative

INFORMATION AND QUESTIONS ABOUT PATIENT’S HEALTH CONDITION

Smoking (how many daily? since?):

Identified chronic dieseases:

Past treatments, operations (varicose veins and others), injuries:

Allergies:

Infections (e.g. HBV, HCV, HIV):

QUESTIONS ABOUT VASCULAR SYSTEM

Previously diagnosed venous system diseases:

Varicose veins (venous insufficiency) in the family (at whom?):

Deep vein thrombosis or pulmonary embolism in the family (at whom?):

ADDITIONAL QUESTIONS

How did you find out about Phlebology Clinic?

In what institution have you treated your problems related to the venous system so far?

QUESTIONS FOR PEOPLE OF FEMALE GENDER

If these issues do not apply to you (male gender), mark: no

Yes

No

Number of pregnancies:

Number of births:

Are you pregnant?

Yes

No

PERSONAL DATA PROTECTION

Klinika Flebologii Sp. z o.o. (Ltd.) with its registered office located at 5 Wawelska St., 02-034 Warsaw, Poland, tax ID no. (NIP): 7010498962, company registration no. (KRS): 0000568625 is the controller of Your personal data. To ensure the protection of personal data Klinika Flebologii has appointed the Data Protection Officer, who is responsible for all matters related to the processing of Your personal data. Should you have questions regarding the manner or scope of processing of Your personal data by Klinika Flebologii or Your rights related to the processing, please contact the Data Protection Officer by letter to the following address Klinika Flebologii, ul. Wawelska 5, 02-034 Warszawa (with annotation “IOD”), by phone at +48 535 443 338, or by e-mail at iod@klinikaflebologii.pl. For more information on the processing of Your personal data, including the purposes of the processing, categories of processed data, recipients of the data, data storage period, or Your rights related to the processing, please see the information clause on the processing of personal data of Patients of Klinika Flebologii, which is available on Klinika Flebologii's website in the "Personal Data" tab (https://klinikaflebologii.pl/RODO).

TERMS AND CONDITIONS OF HEALTHCARE SERVICES

Klinika Flebologii Sp. z o.o. (Ltd.) provides healthcare services following the terms and conditions of the organizational regulation adopted according to Article 23 of the Act of April 15, 2011, on Medical Activity. This regulation specifies, e.g., terms and conditions of providing healthcare services and payments, including rules of registration, canceling an appointment for a healthcare service, preparation for a healthcare service, or the payment terms for a healthcare service. An electronic version of an excerpt from the said organizational regulation is available on Klinika Flebologii's website in the "Regulations" tab (https://klinikaflebologii.pl/regulamin/wyciag-z-regulaminu-organizacyjnego).

STATEMENTS

I declare that I have read the information clause on processing my personal data by Klinika Flebologii Sp. z o.o. (Ltd.), available on its website in the "Personal Data" tab (https://klinikaflebologii.pl/RODO).

I declare that I have read the extract from the organizational regulation of Klinika Flebologii Sp. z o.o. (Ltd.), available on its website in the "Regulations" tab (https://klinikaflebologii.pl/regulamin/wyciag-z-regulaminu-organizacyjnego) and agree to the terms and conditions specified therein.

STATEMENTS

*I hereby:

authorize

not authorize

*First and Last name

Contact details

*Phone no.

*e-mail address

*PESEL (Polish personal ID no.)

*In the case of persons who do not have a PESEL (Polish personal ID no.), please indicate the date of birth

to obtain all information about my health (medical status) and the healthcare services provided to me at Klinika Flebologii Sp. z o.o. (Ltd.)

to obtain my medical records created at Klinika Flebologii Sp. z o.o. (Ltd.)

do not authorize anybody

to obtain information about my health (medical status) and the healthcare services provided to me at Klinika Flebologii Sp. z o.o. (Ltd.)

do not authorize anybody

to obtain my medical records created at Klinika Flebologii Sp. z o.o. (Ltd.)

express my objection

to access after my death to my medical records created at Klinika Flebologii Sp. z o.o. (Ltd.)

CONSENT TO MARKETING ACTIVITIES

*I hereby:

consent to the processing by Klinika Flebologii Sp. z o.o. (Ltd.) of my personal data in the form of the e-mail address for marketing purposes, consisting of encouraging information about Klinika Flebologii and healthcare services provided therein in the form of reviews on Google and I declare that I have read the information clause on processing my personal data by Klinika Flebologii, available on its website in the "Personal Data" tab (https://klinikaflebologii.pl/RODO

agree to receive marketing communications from Klinika Flebologii Sp. z o.o. (Ltd.) as an incentive to provide information about Klinika Flebologii and healthcare services provided therein in the form of reviews on Google.

I have read the regulations

Patient Card - Registration Form

Klinika Flebologii Sp. z o.o.

Klinika Flebologii Sp. z o.o. ul. Wawelska 5, 02-034 Warszawa 22 417 10 00 I +48 735 998 880 rejestracja@klinikaflebologii.pl www.klinikaflebologii.pl

Patient Card of Klinika Flebologii